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MBBS 3: Internal Medicine > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What is hypertension ?

A

high blood pressure is a long-term medical condition in which the BP in the arteries is persistently elevated.
BP > 140/90mm Hg on at least 3 occasions on different days

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2
Q

What is blood pressure?

A

when the heart pumps blood through the arteries the blood puts pressure on the artery walls

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3
Q

Blood pressure is represented by?

A

120/80 mmHg
1. systolic - when hearts contracting
2. diastolic - when hearts relaxing

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4
Q

Staging of hypertension?

A
  1. normal - 90-119/60-79
  2. normal high/prehypertension - 120-139/80-89
  3. mild hypertension - 140-159/90-109
  4. severe hypertension - >160/>110
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5
Q

Normal hypertension?

A

systolic < 120
diastolic < 80

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6
Q

Prehypertension?

A

systolic: 120-139
diastolic: 80-89

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7
Q

Hypertension Stage 1?

A

systolic: 140-159
diastolic: 90-99

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8
Q

Hypertension stage 2?

A

systolic: 160 or higher
diastolic: 100 or higher

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9
Q

Hypertensive crisis?

A

systolic > 180
diastolic > 110

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10
Q

Consequence of high pressure in the arteries?

A

endothelial cells are damaged leading to:
1. myocardial infarction
2. aneurysm
3. stroke

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11
Q

Types of hypertension?

A
  1. primary (essential) hypertension - 95%
  2. secondary hypertension - 5%
  3. resistant hypertension
  4. pregnancy induced hypertension
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12
Q

What is primary hypertension?

A

high blood pressure with no clear cause

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13
Q

Risk factors for primary (essential) hypertension?

A
  1. old age
  2. obesity
  3. salt heavy diet
  4. sedentary lifestyle
    - improvable with lifestyle change
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14
Q

What is secondary hypertension?

A

Elevated BP with an identifiable cause or underlying condition
e.g. Renal disease, Cushing’s syndrome, Phaeochromocytoma, Conn’s syndrome, coarctation of aorta etc.
Note: 5-10% of HTN cases

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15
Q

What are the causes of secondary hypertension?

A
  1. renal parencymal disease
  2. renal artery stenosis
  3. low renal blood flow
  4. endocrine disorders
  5. coartation of the aorta
  6. pre-eclampsia
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16
Q

Resistant hypertension?

A
  • HTN that remains uncontrolled (≥ 140/90 mm Hg)
  • despite treatment with ≥ 3 antihypertensives OR requires ≥ 4 medications to be controlled
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17
Q

Pregnancy induced hypertension?

A

Elevated BP due to increased production of hormones and enzymes during pregnancy

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18
Q

What is a hypertensive crisis?

A

systolic > 180mmHg
diastolic > 120 mmHg
split into:
1. urgency
2. emergency

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19
Q

Hypertensive urgency?

A

> 180/>110mmHg without evidence of end organ damage
- Urgency doesn’t involve symptoms of organ damage.

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20
Q

Hypertensive emergency?

A

> 180/>110mmHg with damage to end organs

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21
Q

What are the signs and symptoms indicative of impairment of end organs?

A
  1. cardiac - heart failure, myocardial infarction
  2. major blood vessels - dissection of aorta
  3. brain - hypertensive encephalopathy
  4. eyes - hypertensive retinopathy
  5. kidneys - hypertensive nephropathy
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22
Q

White coat hypertension?

A
  • elevated blood pressure readings in a clinical setting (caused byanxiety) but normal readings when measured elsewhere
  • In office BPs >140/90 <160/100 mmHg
  • Can convert to sustained HTN.
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23
Q

Masked hypertension?

A

normal blood pressure readings in a clinical setting but consistently elevated readings when measured elsewhere

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24
Q

Isolated systolic hypertension?

A

elevated SBP (≥ 140 mm Hg) with DBP within normal limits (≤ 90 mm Hg)

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25
Q

Types of hypertension under secondary hypertension?

A
  1. Severe hypertension
  2. Resistant hypertension
  3. Target organ damage disproportionate to the degree of hypertension
  4. Hypertensive emergency
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26
Q

Signs suggestive of secondary hypertension?

A
  1. Unusual onset of hypertension
    - Abrupt onset
    - Onset at < 30 years of age [10]
    - Onset of diastolic hypertension at > 65 years of age
    - Exacerbation of previously controlled hypertension
    - Drug-induced hypertension
  2. Unprovoked or significant hypokalemia
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27
Q

Causes of secondary hypertension?

A

RECENT
1. < 40 years of age: thyroid dysfunction, fibromuscular dysplasia, and renal parenchymal disease
2. 40–64 years of age: hyperaldosteronism, thyroid dysfunction, and obstructive sleep apnea
3. ≥ 65 years of age: renal artery stenosis
4. Most common causes in children and adolescents (< 18 years of age) include renal parenchymal disease and coarctation of the aorta.

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28
Q

Renal causes of hypertension?

A

Renal artery stenosis
e.g., due to atherosclerosis, fibromuscular dysplasia, polyarteritis nodosa, aortic arch syndrome

29
Q

Indications for further workup in renal disease?

A
  1. Resistant hypertension
  2. Recurrent flash pulmonary edema
  3. Abdominal bruit
  4. ↑ Serum creatinine (by ≥ 50%) within 1 week of starting an ACEI or ARB
  5. Hypokalemia
  6. Asymmetric kidney size
30
Q

Workup on renal causes of hypertension?

A

Duplex ultrasonography or MRA or CTA of the renal arteries

31
Q

Renal parenchymal disease causes of hypertension?

A
  1. glomerulonephritis
  2. PKD
  3. SLE
  4. renal tumors
  5. atrophic kidney
32
Q

Indications for further workup in renal parenchymal disease?

A
  1. Urinary symptoms
  2. History of excessive analgesic use
  3. Family history of PKD
  4. Abdominal mass (ADPKD)
  5. ↑ Serum creatinine
  6. Abnormal urine analysis (e.g., hematuria, proteinuria)
33
Q

Workup on renal parenchymal disease?

A

renal ultrasound

34
Q

CKD and HTN?

A

Chronic kidney disease can cause HTN

35
Q

Endocrine causes of HTN?

A
  1. Primary hyperaldosteronism
    - Conn syndrome
  2. Pheochromocytoma
  3. Hypercortisolism
    - Cushing syndrome
  4. Hyperthyroidism
  5. Primary hyperparathyroidism
  6. Congenital adrenal hyperplasia
  7. Acromegaly
36
Q

Non-modifiable risk factors for HTN?

A
  1. Positive family history
  2. Race and ethnicity
  3. Advanced age
37
Q

Modifiable risk factors for HTN?

A
  1. Overweight and obesity (greatest modifiable risk factor)
  2. Uncontrolled diabetes
  3. Smoking
  4. Excessive alcohol intake
  5. Diet high in sodium and low in potassium
  6. Physical inactivity
  7. Psychological stress
38
Q

Sympathetic nervous system activities that regulate BP?

A
  • When the BP is decreasing, the activation of the SNS will occur
  • increased SNS activity increases the HR and cardiac contraction
  • this produces Vasoconstriction in the peripheral arterioles and promotes the release of renin from the kidneys
  • The net effect of the SNS activation is to increase arterial BP by increasing CO and systemic vascular resistance
    Note: BP= CO X SVR
39
Q

Activities of vascular endothelium that regulate BP?

A

The vascular endothelium is a single layer that lines the blood vessels, it produces vasoactive substances and growth factors like nitric acid, endothelin etc, these substances are potent vasoconstrictors and increase BP level.

40
Q

Activities of endocrine system that regulate BP?

A

When the angiotensin-II is stimulated in the adrenal cortex, it will secrete aldosterone which stimulates the kidneys to retain sodium and water resulting in increased CO and BP.

41
Q

Activities of the renal system that regulate BP?

A
42
Q

Clinical features of HTN?

A
  1. severe headache
  2. blurred vision
  3. dizziness
  4. N&V
  5. fatigue
  6. confusion
  7. epistaxis
  8. chest pain
  9. SOB
  10. irregular heart rhythm
  11. papilledema
  12. Symptoms of the underlying cause in secondary HTN.
43
Q

Diagnosis of HTN?

A

History and physical examination
1. Risk factors history e.g. DM
2. PE e.g. fundoscopy, BP measurement

44
Q

Investigations of HTN?

A
  1. Urea creatinine and electrolytes, Echo.
  2. Evaluate for target organ damage and causes of secondary HTN.
45
Q

Screening of HTN patients during hospital visits?

Who to screenand when? Evidence supporting hypertension?

A
  1. Screen high risk individuals annually: family history, DM, obese etc
  2. All individuals >40 should get a BP checked/screening annually.
  3. All individuals 18-39 with normal BP previously and no RFs, screen every 3-5 years.
  4. Elevated average BP on at least two readings obtained on at least two separate visits supports a diagnosis of hypertension
46
Q

How to diadnose new HTN?

What to do on examination?

A
  1. Determine if primary or secondary HTN - Is there is any target organ damage?
  2. BMI and waist circumference
  3. Neurological examination
  4. Cardiac examination
47
Q

Routine studies in HTN?

A
  1. Fasting blood glucose
  2. Serum sodium, potassium, and calcium levels
  3. Renal function tests: serum creatinine and eGFR
  4. CBC
  5. TSH
  6. Lipid profile (HDL, LDL, and triglycerides levels)
  7. Urinalysis and urinary albumin-to-creatinine ratio
  8. Electrocardiogram (ECG)
48
Q

Additional studies in additional HTN?

A
  1. Hemoglobin A1c
  2. Fundoscopy
  3. Liver chemistries
  4. Serum uric acid
  5. Echocardiogram
49
Q

Management of HTN

A
  1. lifestyle modification
  2. pharmacological therapy
50
Q

Lifestyle modification?

A
  1. Weight reduction and maintain normal BMI
  2. DASH diet
  3. Dietary sodium reduction: not more than 100 mEq/L (2.4g sodium 1 tsp or 6g sodium chloride) per day
  4. Reduce alcohol and aim to eliminate
  5. Stop smoking
  6. Exercise
    - regular aerobic physical activity at least 30 minutes/day most days of the week
    - 90 -150 minutes per week
  7. Stress management
51
Q

DASH diet?

A
  • More fruits, vegetables, whole grains , low fat dairy, fish, poultry, lean meat, legumes.
  • Reducing salt/ sodium – less than 1500mg to 2300 mg per day
  • Avoid processed foods
  • Plan meals
  • Drink more water – 2 litres or more
52
Q

Antihypertensive medications?

A
  1. alpha blockers - A1 and A2
  2. beta blockers
  3. calcium channel blockers
  4. diuretics
  5. sodium channel blockers
  6. ACE inhibitors/ARBs
  7. direct renin inhibitors
  8. vasodilators
53
Q

Alpha blockers?

A

Alpha blockers - cause peripheral vasodilation of bvs.
1. A1 blockers: Prazosin, Doxazosin, Tamsulosin
- Used in HTN from pheochromocytoma and can be used in BPH
2. A2 blockers: Clonidine, methyldopa

54
Q

Beta blockers?

A

Reduces the workload of the heart and blood vessels, slows the heart and reduces the force by which it beats.
1. (Cardio-)Selective (block beta 1 receptors in the heart
- Atenolol, metoprolol, bisoprolol, esmolol, nebivolol
2. Non (cardio-) selective (block both b1 and b2)
- Propranolol, timolol
3. Combined alpha and beta adrenergic receptor antagonists
- Carvedilol, labetalol

55
Q

Side effects of beta blockers?

A
  1. bradycardia
  2. hypotension
56
Q

Discontinuation of beta blockers or alpha 2 agonists?

A

Do not abruptly discontinuebeta blockersoralpha-2 agonists. They must be slowly tapered to avoid triggering rebound hypertension

57
Q

Calcium channel blockers?

A

Block the movement of extracellular calcium into the cells and cause vasodilation and decreased heart rate.
1. Dihydropyridine CCBs: Amlodipine, nifedipine
2. Non dihydropyridine: verapamil, diltiazem

58
Q

Side effects of calcium channel blockers?

A

bradycardia, heart block, ankle swelling

59
Q

Diuretics?

A

Help the kidneys to inhibit the sodium reabsorption in the distal convoluted tubules and ascending limb of the loop of henle.
1. thiazide
2. loop
3. potassium sparing

60
Q

Thiazide diuretics?

A

inhibit NaCl reabsorption from distal convoluted tubules.
e.g. HCTz, Chlorthalidone

61
Q

Loop diuretics?

A

Preferred choice of diuretic in patients with symptomatic heart failure and CKD (if GFR < 30 mL/min)
e.g. Furosemide, Torsemide

62
Q

Side effects of diuretics?

A
  1. electrolyte imbalances
  2. reduced Na, Cl, K
  3. Fluid volume depletion (monitor for orthostatic hypotension)
  4. impotence
  5. decreased libido.
63
Q

Potassium sparing diuretics?

A

Aldosterone antagonists: Spironolactone, Eplerenone
- Preferred in hypertension due to primary hyperaldosteronism
- Frequently used as add-on therapy in resistant hypertension

64
Q

Epithelial sodium channel blockers?

A

Amiloride
Consider as add-on therapy for patients with hypokalemia who are receiving thiazides.

65
Q

ACE inhibitors?

A

Reduces/prevents the conversion of angiotensin I to II and prevents vasoconstriction.
Captopril, enalapril, ramipril
Side effects; hypotension, dry persistent cough (ass. With bradykinin)

66
Q

ARBs?

A

Blocks angiotensin
- Losartan

67
Q

Direct renin inhibitors?

A

aliskiren

68
Q

Vasodilators?

A

they act directly on the muscles in the arterial walls and prevent the muscles from tightening and arteries from narrowing.
- Nitroglycerin, sodium nitroprusside, hydralazine

69
Q

Treatment goals?

A
  1. Goal is to reduce the overall cardiovascular RFs and control BP by the least intrusive means possible: BP < 140/90 and in diabetics or people with renal disease < 130/80
  2. Benefits of lowering BP
    - Average precent reduction of stroke incidence 35-40%, MI 20-25% and HF 50%
  3. Evaluate adherence to medication and lifestyle modification.
  4. Screen for complications

MBBS 3: Internal Medicine (72 decks)

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